Chronic pain is not a disease (Psychology Today, 27 May 2018)

[adambeyoncelowe]

While I may agree that unproven symptoms count as syndromes or illnesses, rather than specific diseases, the number of assumptions and false ideas in this article is appalling:

The minor to moderate unexplained symptoms present little difficulty in medicine. While they may relate to stress, an associated mental disorder is no more common than in the general population. Extensive research, however, tells us that the more persistent, the greater the number, and the more severe the unexplained symptoms, the more likely is an associated mental disorder, typically depression.6 In a study my group conducted in mostly severe chronic pain patients, 94% had depression.7 This and much other research demonstrate that severe and disabling chronic pain is a symptom associated with serious psychosocial distress, often a major mental disorder such as clinical depression. Indeed, some research indicates that depression itself accounts for the secondary brain changes described above.

Link: https://www.psychologytoday.com/gb/blog/patient-zero/201805/chronic-pain-is-not-disease

Firstly, brain changes in chronic pain, and in other disorders mentioned (I'm mainly thinking of ME here), show different changes in brain function and structure than depression. As I understand it, astrocytes and microglia appear to be involved in chronic pain. In ME, there appear to be distinct areas of hypoperfusion and structural changes that can be differentiated from depression.

Secondly, he makes lots of leaps without recognising the flaws of such assumptions. Rather than accept that correlation =/= causation, he goes on to suggest psychological problems are causative in unexplained syndromes, rather than being a consequence of them. It's a flaw that's even more egregious when you realise that not every patient with these symptoms has MH problems.

Thirdly, he goes on to promote the BPS model as both 'the only way' and 'a neglected' area of medicine (I'm paraphrasing), despite the increasing take-up of BPS models by the DWP, many pain (and other) clinics and other parts of the NHS. It's yet another desperate call for even more of the shockingly poor BPS models we've been subjected to for the last 30 years.

/rantover

 

[Inara]

I'd like to cite @Jonathan Edwards here:
https://www.s4me.info/threads/chron...apy-can-reduce-the-suffering.4176/#post-72812

Of all the many hundreds of people I saw in the clinic with pain not more than a score or so had pain that was inexplicable. And one of those turned out to be lung cancer. One person in three has chronic pain because their discs are squashed down or their cartilage is worn out, or a nerve is pinched. This is just complete crap.

I know "Ye shall not"...but I really wish people who dismiss pain as "psychogenic" would have it. And I'll want them to know it won't stop until they die. I bet lots of them would get depressed, too. And then I'll want others to tell them "You were depressed in the first place" (or "you had a mental health issue") "that led to changes in the brain, and these caused your pain; now we can redeem you! We can change those brain changes back - you only have to want, that's all."

It's so absolutely unbelievably dumb...Instead of thinking the obvious, "hey, those people have severe symptoms that affect their lives - sure you'll be sad, frustrated, maybe even desperate" they reverse it by saying severe symptoms show an underlying mental illness. (I mean, principally this could be an explanation, but it would have to be proven...but we know the rest.)

They really do live in their own reality, and they are fixed on that reality. They are unable to see alternatives. Actually, if they were consequent, they had to diagnose themselves with a "personality/mental disorder".

 

[Alvin]

House of cards

 

[Hoopoe]

If an effective and profitable treatment were found tomorrow, chronic pain would be reclassified as a disease on the same day.

 

[James Morris-Lent]

Not at all accepted in medicine, the alternative biopsychosocial (BPS) model integrates the biological (disease) elements into their psychological/mental and social context.8 The BPS model applies the term ‘illness’ to the universally present psychosocial issues that reflect the impact on patients’ lives of the symptoms for which they sought care—whether or not a disease is present. Thus, most who seek care have an illness, the severity based on the degree of psychosocial distress. Only the BPS model accommodates this distinction. Therefore, chronic pain is an illness with severe psychosocial distress, not a disease.

I haven't seen this 'disease'/'illness' distinction before. Another one for the repository.

severe and disabling chronic pain is a symptom associated with serious psychosocial distress

A seminal insight, to be sure.

Thirdly, he goes on to promote the BPS model as both 'the only way' and 'a neglected' area of medicine (I'm paraphrasing), despite the increasing take-up of BPS models by the DWP, many pain (and other) clinics and other parts of the NHS. It's yet another desperate call for even more of the shockingly poor BPS models we've been subjected to for the last 30 years.

Yes, well, that is the stratégie politique du jour. Claim your side is under siege and losing. It feels good to play victim.

___
This whole thing with psychogenic pain baffles me. Of all the symptoms I have ever experienced as a result of anxiety or sadness or whatever - nausea, wooziness, headache, palpitations, shortness of breath, diarrhea, weakness, indigestion, tiredness, etc. - none remotely resembled 'pain' in the way we usually mean it, and none were not obviously linked with the 'psychosocial' 'distress' I was going through at the time.

I think this category is empty.

 

[Little Bluestem]

It's so absolutely unbelievably dumb.

And so absolutely unbelievably cruel.

 

[Sly Saint]

Confounding and the Biopsychosocial Model
by Chris Centeno, MD / June 11, 2017
Interesting article.

BIOpsychosocial or bioPSYCHOSOCIAL?
The idea put forth by the biopsychosocialist belief is that patients with chronic pain have a biologic component that interacts with psychology and their social context. As a basic idea, it’s innocent enough. We’ve seen many patients through the years who need to be educated about what’s wrong when they’ve developed the wrong idea about their disease. For example, they believe that’s what’s on their MRI is awful, but in fact, it may be little different than the MRI of most people their age who don’t have pain.

However, in practical experience, through the years the biopsychosocialists have always meandered off the proverbial farm. Rather than considering pain a physical phenomenon that can sometimes impact psychology (BIOpsychosocial or Bps), or that tissue damage and psychology are equally weighted (BIOPSYCHOSOCIAL or BPS), they almost always trend towards considering psychology dominant in this calculus (bioPSYCHOSOCIAL or bPS).

Confounding and the bPS Model
Bad research into the bPS belief is deceptively easy to perform. Why? You simply administer a questionnaire that measures catastrophizing and correlate that to the outcome of a therapy. Catastrophizing means that the patient believes that their illness is worse than it really is and as a result, they believe they won’t improve or get better. So if higher levels of catastrophizing correlate to worse outcomes, you have a nice little study. The problem is that there are two reasons patients have these beliefs. One is that they have a misconception about their injury provided by their providers and the other is that they are legitimately injured and based on reasonable observation of their own condition, reasonably hold the belief that they won’t improve.

Confounding is a real problem in research and is king in bPS studies. Confounding is when something that hasn’t been understood may be causing the effect you observe in your research. As an example, if you notice that a group of people have higher anxiety than the normal population when they work, you might conclude the group has an anxiety disorder. However, if you didn’t note that the group you studied was made up of mostly test pilots, then your conclusion is erroneous, as it’s reasonable to conclude that test pilots have an anxiety provoking job. The same is true in bPS studies.

How Did We Get Here? Imaging Pain with a Structural MRI is a Bad Idea
The bPS model began after it became clear that MRI didn’t explain many chronic pain conditions. Given that an MRI shows the structure of tissue and oftentimes there was a poor correlation between that structure and pain, the conclusion was that the pain wasn’t due to tissue damage, but instead due to other factors like psychosocial issues. However, that boat began to take on water with the following studies:

• Research by Apkarian on how parts of the brain atrophied in patients with chronic low back pain and that atrophy had no correlation with bPS factors
• A study showing that when you were able to kill the pain signals coming from injured facet joints in the neck in whiplash patients, their anxiety and other psychosocial metrics normalized
• Studies showing that the multifidus muscle in the low back atrophied in patients who have chronic low back pain

The NHS has Helped Spread the bPS Model
National health systems like those in the UK and Canada have always had a US problem. Our well-monied health system allows for some of the most technologically advanced care on earth en masse. Add in funding from NIH that dwarfs anything these governments can muster and you get a health care arms race. The citizens of these countries want all of the glitzy stuff available in American healthcare, but paying for these technologies in a government funded system is tough. Hence, they have no choice but to make cuts elsewhere and patients in chronic pain are easy pickings, as they often have no way to substantiate their diagnoses with structural MRI imaging. As a result, bPS proponents have always done well in these countries. They are making the downhill argument to underfunded national health systems when they tell politicians that chronic pain patients have nothing really wrong that can’t be fixed with a good psychology session or re-education. Hence, it’s not surprising that these changes denying disability payments due to bPS philosophy in the U.K’s NHS have recently come under fire from academics.

My biggest concern is that we’re now teaching a generation of physical therapists in the UK and Canada (and more recently the US) to take the easy way out. Rather than learning a craft and spending the thousands of hours they need to get educated about how to help patients in chronic pain, we’re letting them take the bPS cop out. When the patient doesn’t get better, it’s the patient’s fault and not the clinician’s.

full article here
https://regenexx.com/blog/confounding-biopsychsocial-model/

(warning; there are ads on this site.)

 

[Saz94]

Huh, I wonder why 94% of people with chronic severe pain would have depression...

 

[feeb]

National health systems like those in the UK and Canada have always had a US problem. Our well-monied health system allows for some of the most technologically advanced care on earth en masse. Add in funding from NIH that dwarfs anything these governments can muster and you get a health care arms race. The citizens of these countries want all of the glitzy stuff available in American healthcare, but paying for these technologies in a government funded system is tough. Hence, they have no choice but to make cuts elsewhere and patients in chronic pain are easy pickings, as they often have no way to substantiate their diagnoses with structural MRI imaging.

It is an interesting article, but it goes into a pretty weird flex here. If the BPS hegemony was caused by the US having better, more comprehensive, more modern healthcare than the UK and Canada, then surely no patients in the US would ever be told that their chronic pain only exists in their heads? But we know that they do.

 

[rvallee]

It is an interesting article, but it goes into a pretty weird flex here. If the BPS hegemony was caused by the US having better, more comprehensive, more modern healthcare than the UK and Canada, then surely no patients in the US would ever be told that their chronic pain only exists in their heads? But we know that they do.

Right target but for the wrong reasons. For all its faults, and it has many, the one redeeming quality of the US health care is tort. Most universal health care systems are "no fault", mistakes are to be buried and silenced, no one is ever to be blamed (except the patient, of course, always blame the patient). In the US system, misdiagnosis can carry actual consequences and it makes bold assertions without evidence, such as "there is no disease and you can aim for full recovery" liable malpractice (hello, Mayo clinic and other lying liars, see you in court in a few years).

This is the only advantage the US health care system has: you can't bullshit your way officially and lack of due diligence has consequences. It makes "I don't know" the right answer to complex problems, whereas some systems like the NHS will actively encourage their practitioners to promote completely made-up pseudoscience like the psychosocial model, telling them they will be shielded from all liability if ever it comes to that.

That's likely the main reason the US has been reluctantly leading the way out of making bold assertions about the psychosomatic nature of ME. Since they are simply not backed by evidence practitioners understand they may face consequences for straight-up lying to their patients, they do not have the protection the NHS gives its GPs, instead actually encouraging them to straight-up to go all in and gaslight their patients because they think it's cheaper.